abcde assessment

Assessment is definitely drummed into nursing students from the early stages as one of the most important aspects of nursing care. What exactly does the appropriate governing body mean by assessment? Why is it so important and why has it more recently become a nursing role in heath care? The NMC (nursing and midwifery) code of conduct, performance and ethics for nurses and midwives advocates that;

You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support.

Assessment in a way is allowing the nurse to advocate on behalf of the patient following the development of the nurse’s understanding of the patient and any relevant information that may influence the patient’s care.

Having just started a placement in a busy accident and emergency department which is seeing in excess of 400 patients everyday, assessment skills are definitely going to help me. However, research suggests that assessment skills are less than satisfactory until the practitioner has had appropriate experience in that particular area of assessment. Suggesting therefore that the skills associated with assessment cannot be taught but are developed over years of training and experience. How exactly are they going to expect me to function in this department then? Well I suppose with my unsatisfactory assessment skills… or by the use of assessment tools. Assessment tools are useful documents, I’m sure any heath care worker would agree, especially in the absence of skill and clinical competence. However, when they are made into policy at a hospital or department, isn’t this suppressing the clinical judgement and autonomy of the practitioner somewhat?

Assessment tools are built into most hospital environments as a way of standardising the processes. On the ward for example, the Roper, Logan and Tierney model for assessment of the Activities of Living. I’m sure every nurse rolls their eyes when they hear this model mentioned as pretty much every piece of paper work they ever fill in on the ward is based on this model. With good reason of course (isn’t the NHS known for being reasonable?). It is an excellent assessment tool for the generally unwell medical or surgical patient as it successfully encompasses the patient’s everyday activities and divides them into 12 manageable sections. When this tool is used by a confident and experienced practitioner, the patient will benefit greatly from a individually tailored care plan based on their activities of living. However, when used by an untrained member of staff, a novice or a student perhaps the positive outcomes of the potentially thorough assessment won’t be as profound.

Although it is in the patient’s best interests for their initial assessment to be thorough, it isn’t life threatening if some parts are missed out. So now, especially in day surgery, new admission and assessment checklists have been developed to allow the practitioner to be safe in the knowledge that they haven’t missed out something major. It will also give the qualified nurses peace of mind when the untrained staff complete an assessment that nothing has been missed. However, in accident and emergency, some assessments are in life threatening situations and so the qualified staff have to be able to refer to an assessment tool off the top of their head and think on their feet. It definitely isn’t any use to the patient having a cardiac arrest that all the appropriate paperwork is completed until after the patient’s condition is managed.

The resuscitation council advocate a process that I’m sure all student nurses are sick to death of called the ABCDE assessment. This framework is very effective in assessing and managing the patient in accident and emergency or anywhere where a patient may deteriorate or become acutely unwell. A stands for airway and quite simply means does the patient have an airway? If yes, is it patent or semi-patent? If no, the occlusion needs to be managed before we can move on to B. B stands for breathing. The experienced practitioner will carry out a comprehensive respiratory assessment but us lowly student nurses go by; is the patient breathing? At what rate? With what depth and pattern? Is there any noises or any evidence of the use of accessory muscles? Is the patient cyanosed? Consider the need for a chest x-ray. If the patient shows signs of distress, 100% oxygen should be given through a non re-breathe mask. C stands for circulation. Does the patient have a pulse? What is their heart rate, rhythm and amplitude? What is their systolic, diastolic, mean and pulse pressure? Are they pale? What is their capillary refill time? It is now that you connect the patient to a cardiac monitor, consider recording a 12 lead ECG and get expert help with some routine blood tests. D stands for disability. Here you should do a Glasgow Coma Score or a AVPU assessment to establish the patient’s level of consciousness. You should also consider a blood glucose test. E stands for exposure. Here you check the patient from head to toe for any evidence of fractures, bleeding or rashes. Alongside this assessment framework is the MOVE management framework. This stands for monitor, oxygen, venous access and expert help. When assessing the patient, if you notice anything out of the ordinary you need to call for help so that the problem can be managed or if the patient is established as in need of CPR then this must be commenced while you wait for help to arrive. An important aspect of nursing care that is often forgotten in this form of emergency assessment is:

You must treat people as individuals and respect their dignity.

Although sometimes it can be hard to do in emergency situations, I’m going to try and assess my own nursing competency in this particular requirement. You never know, the patients might thank me for it…